Of 611 participants, 20.5% scored above the cut-off on the GHQ–12 and
3.4% scored as having probable PTSD. Higher risk of psychological distress was
associated with younger age, female gender, weaker unit cohesion, poorer
perceived leadership and non-receipt of a pre-deployment stress brief.
Perceived threat to life, poorer perceived leadership and non-receipt of a
stress brief were risk factors for symptoms of PTSD. Better self-rated overall
health was associated with being a commissioned officer, stronger unit
cohesion and having taken a period of rest and recuperation. Personnel who
reported sick for any reason during deployment were more likely to report
psychological symptoms. Around 11% reported currently being interested in
receiving help for a psychological problem.

Conclusions

In an established operational theatre the prevalence of common
psychopathology was similar to rates found in non-deployed military samples.
However, there remains scope for further improving in-theatre support
mechanisms, raising awareness of the link between reporting sick and mental
health and ensuring implementation of current policy to deliver pre-deployment
stress briefs.

Much is already known about the mental health of UK armed forces
personnel.1–5
However, most research to date has examined the psychological well-being of
military personnel either before or after deployment relying on retrospective
accounts to examine the impact of deployment experiences; there is currently
scant evidence concerning the psychological health status of personnel while
they are deployed on operations. It is known that relatively small numbers
access field mental health teams (the unit by which formal mental health is
delivered on
operations)6,7
but these figures are unlikely to be a true reflection of the prevalence of
mental health problems since there is a considerable body of evidence that
suggests that significant numbers of personnel who might benefit from mental
healthcare or support do not access services because of
stigma.8–10

Since 2003, the US military have been conducting annual surveys of the
psychological health of personnel while on deployment to Iraq and, to a lesser
extent,
Afghanistan.11
Their findings have helped to inform policy and practice changes. For example,
they have decreased their standard tour length from 15 to 12 months and
increased the numbers of deployed mental health providers to bolster the
support options available to deployed personnel. This paper reports the
findings of the first systematic survey of UK armed forces personnel while on
deployment, which was conducted to evaluate their mental health status and
factors that may affect their psychological health, as well as to identify any
obvious gaps in the provision of support on operations.

Method

The study was conducted in Iraq in January and February 2009 during
Operation TELIC 13 (the deployment period between December 2008 and June
2009). Operation TELIC is the codename for UK military operations in Iraq
since 2003. Participants were eligible for the study if they were members of
any of the three UK armed forces (Royal Navy, army and Royal Air Force), and
were deployed in Iraq during the study data-collection period. The target
sample size was 600 personnel, representing approximately 15% of the deployed
force; half based within the main base in Basra (known as the Contingency
Operating Base) and half outside. True random sampling was not possible
because of the need to ensure an adequate coverage of personnel from very
small operating bases, and operational reasons (this was a theatre of war);
special forces personnel were not included in the sample. Instead, after
discussion with the medical and personnel staff officers based in the UK
operational headquarters, purposive sampling was conducted to ensure an
adequate spread of personnel and locations. Information on the service and
rank profile of the deployed force was obtained from the divisional personnel
report, allowing examination of the representativeness of the study
sample.

Data were collected using a self-report questionnaire. The Operational
Mental Health Needs Evaluation (OMHNE) survey team, which included two
military personnel, travelled to eight locations to distribute and collect
questionnaires (Fig. 1). The
locations included not just the main base in Basra, but also Baghdad,
locations in Basra City and other units deployed across Southern Iraq. All the
main UK bases were visited, excluding some remote locations. Location
commanders were asked to assemble all available personnel so that the survey
team could provide information about the study and distribute questionnaires.
The survey team were explicit in briefing the potential respondents that,
unlike other deployment activities, completion of the questionnaires was
voluntary. Personnel were also assured that all information was confidential,
that their individual responses would not be reported to commanders and that
no individual would be named in any report about the study. Respondents were
informed that personal identification information would be separated from the
questionnaire by the study team and stored separately. The questionnaire took
approximately 25 min to complete. Participants were not given any payment or
any other inducement for taking part in the study. Once completed,
participants placed their questionnaire in an envelope and sealed it before
giving it to a member of the study team.

The survey tool included questions about sociodemographic and military
characteristics, deployment experiences, unit factors such as cohesion and
leadership, and force health protection factors such as receipt of a stress
brief and taking a period of rest and recuperation (R&R) in a location
outside the operational theatre. The primary outcome measures assessed were:
psychological distress, symptoms of post-traumatic stress disorder (PTSD), and
self-rated health. Psychological distress was assessed with the 12-item
General Health Questionnaire
(GHQ–12),12
with those scoring four or more classified as ‘cases’. Symptoms of
PTSD were measured with the 17-item National Center for PTSD Checklist
(PCL–C),13
with cases defined as those scoring 50 or more. The GHQ–12 and
PCL–C have been routinely used in a variety of studies conducted into
the health of UK armed forces personnel in non-deployed settings.
Self-reported health status was assessed with a single item that asked
respondents to rate their health from poor to excellent on a five-point Likert
scale. Participants were also asked about reported sickness and help-seeking
during the deployment. Combat exposure was assessed with a 17-item measure
that asked about the frequency of exposure to potentially traumatic combat
events. Unit cohesion and leadership were each assessed with four-item
measures that have been used in other studies of health in the UK armed
forces.5 A number of
other issues were also assessed in the questionnaire; however, this paper
concentrates on deployment-related factors and their possible impact on
health.

Approval to conduct the study was granted by the Ministry of Defence
Research Ethics Committee (MODREC) (Protocol No. 839/194). All participants
gave written informed consent.

Analysis

Analyses were carried out in STATA 10.1 for Windows. Statistical
significance was defined at the level of P<0.05. The association
between independent variables (demographic and military characteristics,
deployment experiences, unit cohesion, leadership and health protection
factors) and health outcomes was examined using regression analyses.
Psychological distress (caseness as assessed by the GHQ–12) was examined
using binary logistic regression analyses to generate odds ratios (ORs).
Because of the small number of PTSD cases, the study did not have sufficient
power to treat this as a dichotomous variable in multivariate analyses.
Instead, the measure was used as a continuous scale. As the data were highly
skewed, negative-binomial regression analysis was conducted, using the
PCL–C score as a count variable. The PCL–C total score was recoded
from 17 to 85 to range from 0 to 68 for the purpose of the regression
analysis. Self-rated health was assessed on an ordinal scale, therefore
ordinal regression analysis was used to examine the association between
independent variables and self-rated overall health. As very few respondents
rated their health as ‘poor’, the responses ‘poor’ and ‘
fair’ were combined, producing a four-point scale: excellent,
very good, good and fair/poor.

The relationship between reporting sick during deployment and the
self-report mental health outcomes were analysed using χ2-tests
for GHQ–12 and Mann–Whitney U-tests for PCL–C.

Results

Of 612 personnel approached to take part, 611 (99.8%) completed the survey.
This represented approximately 15% of the UK armed forces personnel deployed
in Iraq on Operation TELIC 13. Sample characteristics are described in
Table 1, which indicates that,
in terms of service and rank, the sample is broadly representative of the
deployed population.

Demographic characteristics of the Operational Mental Health Needs
Evaluation (OMHNE) sample studied in relation to the total Operation TELIC 13
population

Health outcomes

Health outcomes are shown in Table
2. In total, 125 of the 602 respondents who completed the
GHQ–12 (20.8%) were classified as cases. Of the 588 respondents who
completed the PCL–C (3.4%), 20 were classified as PTSD cases. Most
respondents (n = 564/609, 92.6%) reported their overall health to be
good, very good or excellent.

Risk factors and self-reported health status

Those who scored above the cut-off on the GHQ–12 were more likely to
be younger, female, in the army and of junior rather than of senior or officer
rank (online Table DS1). Stronger unit cohesion, better perceived leadership
and receipt of a pre-deployment stress brief were associated with a lower
likelihood of scoring above the GHQ–12 cut-off. There was no
relationship between GHQ–12 outcome and reservist status or deployment
factors such as location in theatre or combat exposure. In multivariate
analysis, the variables that remained statistically significant independent
risk factors were: younger age, female gender, weaker unit cohesion, poorer
perceived leadership and non-receipt of a stress brief.

An increased risk of reporting PTSD symptoms was associated with junior
rank, having felt in danger of being killed and higher combat exposure (online
Table DS2). Better perceived leadership and receipt of a stress brief were
associated with a lower risk of reporting PTSD symptoms. In multivariate
analysis, the variables that remained statistically significant independent
risk factors for reporting symptoms of PTSD were having felt in danger of
being killed, poorer perceived leadership and non-receipt of a stress
brief.

Poorer overall self-rated general health was associated with non-officer
rank, reservist status, poorer unit cohesion, poorer perceived leadership,
non-receipt of a stress brief and not having taken a period of R&R (online
Table DS3). In multivariate analysis, the variables that remained
statistically significant independent risk factors for poorer self-rated
health were non-officer rank, poorer unit cohesion and not having taken a
period of R&R.

Relationship between help-seeking during deployment and mental
health

Personnel who reported sick on at least one occasion for any reason were
significantly more likely than those who had not reported sick to score above
the cut-off on the GHQ–12. They also reported significantly more
symptoms of PTSD (Table 3).
Admission to the field hospital did not significantly affect the likelihood of
scoring above the cut-off on the GHQ–12 or reporting symptoms of
PTSD.

Those who reported having experienced a significant stressful, emotional or
family problem were significantly more likely to score above the cut-off on
the GHQ–12 and to report more symptoms of PTSD
(Table 3). Of those who
reported having experienced a problem during the deployment (n = 151,
26%), less than 40% (n = 56) reported having received help. Where
help was received, it was most commonly from a friend (n = 38, 68% of
those who had experienced a problem and received help) or the chain of command
(n = 24, 43%). Help from a chaplain or medical professional was less
common, being received by 10 (18%) and 7 (13%) respectively.

Those who were currently interested in receiving help for a significant
stressful, emotional or family problem were significantly more likely to score
above the cut-off on the GHQ–12 and to report more symptoms of PTSD
(Table 3). Respondents who
reported being currently interested in receiving help (n = 58) were
more likely to be younger (mean age 25.3 v. 27.9 years, t = –
2.5, P = 0.01) and of junior rank (χ2 = 13.1,
P = 0.001), however there was no association with service
(χ2 = 0.23, P = 0.89) or gender (χ2 =
0.003, P = 0.96).

Discussion

Main findings

The OMHNE survey aimed to provide information about the health of deployed
UK service personnel. Although the OMHNE was a novel process for the British
armed forces, over 600 responses were successfully collected (with a 99.8%
response rate), entered into a statistical database, analysed and briefed back
to senior commanders within a 6-week period. This confirms that the OMHNE is a
viable approach to obtaining real-time health online Table DS3 and personnel
data on operations.

The OMHNE produced a number of key findings. First, the prevalence rates of
psychological distress and PTSD found within this study are in keeping with
those reported in other recent studies that surveyed UK armed forces personnel
when they were not on
deployment.1,5
So too are the reported ratings of overall
health.14 These
prevalence rates are lower than in other high-stress occupational groups such
as police officers, doctors in emergency departments and disaster
workers.15–17
Second, the data showed that the main risk factors for psychological distress
(as measured by GHQ–12) were: female gender, weaker unit cohesion,
poorer perceived leadership and non-receipt of a stress brief. The main risk
factors for reporting symptoms of PTSD were: perceived threat to life, poorer
perceived leadership and non-receipt of a stress brief. Third, better
self-rated health was associated with officer rank, stronger unit cohesion and
having taken a period of R&R. Finally, we found that more than 10% of
personnel were currently interested in receiving help for a stress, emotional
or family problem; these were more likely to be individuals in the junior
ranks.

Although there are reasons for hypothesising that, on the one hand deployed
service personnel might experience better mental health than those not
deployed, for example due to the ‘healthy worker
effect’,18
but on the other hand worse mental health due to increased exposure to
stressors, this survey found that in practice, there seemed to be little
overall effect of deployment on mental health. It may be that the positive and
negative aspects of deployment are equally balanced. Another possible
explanation is that Operation TELIC 13 was a low operational intensity
environment, which is often characteristic of a military operation coming
towards its end. This explanation is supported by the most recent annual US
survey of personnel deployed to Iraq, the Mental Health Advisory Team (MHAT)
VI, which has reported the lowest rate of psychological problems since
2004.19

The relationship between demographic factors and health outcomes in the
OMHNE was mostly consistent with findings of earlier studies in the UK armed
forces. Reporting of better overall health by officers has been found in an
earlier study of UK armed forces
personnel14 and is
thought to reflect the general finding of better self-rated health among those
of higher socioeconomic
status.20 The
absence of any gender difference in symptoms of PTSD or self-rated health has
been previously reported by Rona et
al.14,21
However, the relation between gender and psychological distress assessed with
the GHQ is not consistent across studies. In common with the OHMNE, Hotopf
et al22
found that female personnel who had been deployed in Bosnia were more likely
to score above the cut-off on the GHQ; however, among Gulf War veterans, this
was more common among male
veterans.23
Although this appears to be an area worthy of further investigation, this
finding may represent different pressures on female service members while
deployed compared with the home environment.

Deployment-related factors such as time spent outside the base in a hostile
area, were mostly not significant risk factors for health problems. This is in
contrast to findings from a study of UK personnel serving on earlier, more
intensive, Iraq deployments, in which time spent in a forward area was a
significant risk factor for
PTSD.24 However, in
the current study, although being in a hostile area was not in itself a risk
factor for poorer mental health, feeling in danger of being killed was a risk
factor for symptoms of PTSD, consistent with other
studies.24,25
This indicates that the perceived danger of deployment is most salient and is
consistent with Ehlers &
Clark’s26
cognitive model of PTSD, which proposes that the perceived level of threat is
more important than its actual severity in the development of PTSD.

It is encouraging that several of the variables that were associated with
health outcomes in the multivariate analyses are potentially modifiable, i.e.
unit cohesion, leadership, receipt of a stress brief and provision of R&R.
There has been much written about the benefits, in terms of mental health, of
working within units that enjoy good leadership and good cohesion between unit
members,24,27,28
and the modern military do not need to be reminded of the importance of
cohesion and leadership on morale, mental health and military effectiveness.
Social support offered by a cohesive unit and supportive leadership may also
protect against physical ill health by acting as a buffer against the
potentially negative impact of stressful
events.29 The
results of this study are consistent with these findings.

This study found that, unlike previous UK research into pre-deployment
briefings carried out during Operation TELIC
1,30 those who
reported remembering having had a pre-deployment brief reported significantly
better mental health than those who did not. It is possible that those units
that ensure their personnel receive a pre-deployment briefing may also ensure
that the well-being of unit members is protected in other ways. However, this
effect was not simply related to the quality of unit leadership since the
finding remained significant after the quality of leadership was controlled
for. A similar finding was demonstrated by the US Mental Health Advisory Team
who also found that units who reported receiving standardised pre-deployment
educational packages had better mental health than those who did not; again
the effect remained after controlling for
leadership.31
Previous UK military research has shown that only those briefings that
personnel recall as having been useful are likely to be beneficial in terms of
mental health.32
Thus, the OMHNE finding may be as a result of pre-deployment briefings having
become more salient and focused since Operation TELIC 1, perhaps as a result
of the considerable experience that the UK armed forces now have in preparing
personnel for deployment.

Our findings suggest that those who reported sick on at least one occasion
had poorer self-reported mental health. Although this could be representative
of comorbid psychological ill health with physical illness, this is not
supported by the finding of minimal effects on mental health associated with
being admitted to the field hospital. Although the OMHNE did not attempt to
explore the reasons why personnel may have reported sick, it is well-known
that the dynamics of the clinician–patient consultation is often more
complex than the simple request by an individual for advice or
treatment.33
Increased attentiveness to possible signs of mental health problems among
those who report sick could help to identify those in need of help.

One strength of this study is that it achieved a very high response rate.
The lower response rate found in other studies (e.g. Fear et
al)1 may well
occur because of difficulty in locating a highly mobile population outside of
a deployed environment rather than because of reluctance to take part in
research.

Implications

The OMHNE study has identified a number of important areas regarding the
psychological well-being and mental health of UK military personnel while
deployed. A small but not insignificant number of personnel reported being
interested in receiving help at the time of survey completion. However, only a
small percentage of those who seek support do so from formal available sources
(medical centres, welfare agencies or the field mental health teams),
suggesting that barriers exist, either cognitively or practically, which
prevent some personnel from accessing this support. Forward provision of such
support is likely to make access easier, reduce the likelihood that internal
stigma will act as a barrier and is in keeping with the psychiatric doctrine
of operational
care.34

Most units have some in-house medical support, which can be delivered by
medical assistants or combat medical technicians, who support the unit medical
officer. Medical assistant/combat medical technicians training does not
currently cover the nature of mental health disorders nor does it aim to
prepare them to conduct a psychologically focused consultation. Raising
awareness among medical assistant/combat medical technicians staff of the
relationship between reporting sick and mental health, alongside further
training in this area, may help to identify those in need of psychological
help.

There is already joint policy that mandates that deploying personnel are
provided with a pre-deployment
brief.35 The OMHNE
data suggest that this policy needs to be more rigorously enforced while
ensuring that the briefs are both suitable for the intended audience and of a
good quality.

Study limitations

The small number of PTSD cases in this sample meant the study did not have
sufficient power to examine risk factors for scoring above the threshold for
having probable PTSD. However, our other larger studies have permitted such
analysis, albeit not in an operational
setting24 and
comparisons with these findings have been discussed earlier. The small number
of reservists in the study meant that we were unable to confirm or refute our
previous work showing that reservists had significantly worse post-deployment
mental
health.3,5

The study used self-report measures and thus, in keeping with all such
measures, it is not possible to diagnose mental ill health reliably; diagnosis
requires a clinical interview (which was not done during OMHNE). Scoring over
a specified level on the questionnaires increases the probability that an
individual has a defined mental health disorder, but is not definitive. The
questionnaires should therefore be considered more as screening than
diagnostic instruments.

Since the OMHNE data were derived from a non-random sample of personnel,
one might be cautious when generalising the findings to all personnel deployed
to Operation TELIC 13 and to other operations. The sample was, however,
selected only after discussion with in-theatre operational planners and all
efforts were made by the OMHNE team to minimise selection bias by ensuring
that everyone who was off-duty at a unit location completed a questionnaire.
It may be, however, that those who did not want to complete questionnaires
made themselves unavailable during visits by the research team. Conducting an
epidemiological study in a war zone inevitably entails difficulties in
accessing all eligible personnel. However, the OMHNE sample is similar in
terms of rank and service to the Operation TELIC 13 population from which it
is drawn (Table 1), which
offers some reassurance that we did not have significant recruitment bias.

Office of the Surgeon Multi-National Corps-Iraq and Office of The
Surgeon General United States Army Medical Command. Mental Health Advisory
Team (MHAT) VI. Operation Iraqi Freedom 07–09. Office of the
Surgeon Multi-National Corps-Iraq and Office of The Surgeon General United
States Army Medical Command, 2009
(http://www.armymedicine.army.mil/reports/mhat/mhat_vi/MHAT_VI-OIF_Redacted.pdf).